Early Intensive Versus Minimally Invasive Approach to Postoperative Hemodynamic Management After Subarachnoid Hemorrhage

• Published in: Stroke (1970) Vol. 45; no. 5; pp. 1280 - 1284
• Main Authors: Mutoh, Tatsushi, Kazumata, Ken, Terasaka, Shunsuke, Taki, Yasuyuki, Suzuki, Akifumi, Ishikawa, Tatsuya
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD American Heart Association, Inc 01.05.2014; Lippincott Williams & Wilkins
• Subjects: Administration, Intravenous; Aged; Biological and medical sciences; Brain Ischemia - drug therapy; Brain Ischemia - etiology; Brain Ischemia - prevention & control; Cardiac Output - physiology; Central Venous Pressure - physiology; Disease Management; Early Diagnosis; Female; Fluid Therapy - instrumentation; Fluid Therapy - methods; Humans; Male; Medical sciences; Middle Aged; Monitoring, Physiologic - instrumentation; Monitoring, Physiologic - methods; Neurology; Neuropharmacology; Neurotransmitters. Neurotransmission. Receptors; Pharmacology. Drug treatments; Postoperative Period; Serotoninergic system; Severity of Illness Index; Subarachnoid Hemorrhage - complications; Subarachnoid Hemorrhage - diagnosis; Subarachnoid Hemorrhage - therapy; Time Factors; Treatment Outcome; Vascular diseases and vascular malformations of the nervous system; Postoperative; Stroke; Nervous system diseases; Subarachnoid hemorrhage; fluid therapy; Cardiovascular disease; delayed cerebral ischemia; Cerebral disorder; Vascular disease; Clinical management; Treatment; Central nervous system disease; Brain ischemia; Hemodynamics; hemodynamic management; Comparative study; Cerebrovascular disease; subarachnoid hemorrhage
• ISSN: 0039-2499; 1524-4628
• DOI: 10.1161/STROKEAHA.114.004739

BACKGROUND AND PURPOSE—The results of previous studies suggest that early goal-directed fluid therapy (EGDT) reduces delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage, but the effects of EGDT on clinical outcomes are still unclear. This study aimed to determine whether EGDT improves outcomes compared with standard less-invasive hemodynamic therapy. METHODS—This study included 160 patients treated within 24 hours after subarachnoid hemorrhage, randomized to receive either (1) EGDT guided by preload volume and cardiac output monitored by transpulmonary thermodilution (treatment group) or (2) standard therapy guided by fluid balance or central venous pressure, assisted by uncalibrated less-invasive cardiac output monitoring during hyperdynamic therapy in patients with clinical or radiological indications of DCI (control group). DCI determined by clinical or radiological findings and functional outcome determined by the modified Rankin Scale score at 3 months were compared between groups. RESULTS—For all clinical grades combined, there were no significant differences in the rates of DCI (33% versus 42%; P=0.33) or modified Rankin Scale score of 0 to 3 at 3 months (67% versus 57%; P=0.22) between the 2 groups. For patients with poor clinical grade, those who received EGDT had a significantly lower rate of DCI (5% versus 14%; P=0.036), modified Rankin Scale score of 0 to 3 at 3 months (52% versus 36%; P=0.026), and shorter length of intensive care unit stay (14 versus 17 days; P=0.043) than those who received standard therapy. CONCLUSIONS—EGDT is beneficial for reducing DCI and improving postoperative functional outcome in patients with poor clinical grade. CLINICAL TRIAL REGISTRATION—URLhttp://www.clinicaltrials.gov. Unique identifierUMIN000007509.